Invasive CardiologyInvasive Cardiology::PerPerccutanutaneouseous InterventionIntervention..

Prof Dr Rasim ENARProf Dr Rasim ENAR

İÜ. CTF. İÜ. CTF. Department of Department of CardiologyCardiology

Types of percutaneous Types of percutaneous interventionintervention::A. A. DiagnosisDiagnosis:: • Diagnostic CatheterisationDiagnostic Catheterisation: : • Right and left heart cath.Right and left heart cath.• Coronary angiographyCoronary angiography..• EEPSPS, , IIVUS…VUS…B.TB.Treatmentreatment::1- 1- SStandart Ptandart PCICI:: PTCA, Stent PTCA, Stentss..2- 2- NNeeww İntra İntraccoronoronaryary devicesdevices:: At Athhereerecctomtomyy, ,

RotablatRotablatoor, Laser,r, Laser, BraBrachychytthheraperapyy (rad(radiiotothheraperapyy), T), Thhromberombecctomtomyy, distal-, distal-protectionprotection..

3- Non3- Non-c-coronoronaarryy interventionintervention::ValvuloplastValvuloplastyy, Septal abla, Septal ablatition, septal defeon, septal defecct t

closureclosure, , valvevalve repla replacecemmeenntt ,PM, ICD, CRT,PM, ICD, CRT….….

CATHETERISATIONCATHETERISATION

DefinitionDefinition::• Invasive procedures for the diagnosis and Invasive procedures for the diagnosis and

assesment severity of cardiovascular disease.assesment severity of cardiovascular disease.

• Catheterisation of right and left heart and Catheterisation of right and left heart and coronary angiography. This procedure is done coronary angiography. This procedure is done by using various methods and various by using various methods and various catheters. catheters.

Catheter:Catheter: Are small plastic tubes which has Are small plastic tubes which has empty tunel inside.empty tunel inside.

Main condition for Main condition for PPCI:CI::…”:…”Have to Have to bebe”…”… Appropriate Cath Lab and Appropriate Cath Lab and Staf.Staf.

• Semi-sterilSemi-sterilee CatheterisationCatheterisation Laborat Laboratoorryy:: A movable table A movable table for the patient lying supinefor the patient lying supine, - film , - film ccamera, amera, a scope with a scope with rotating headrotating head, -an, -anggiyograiyographyphy andand monitors for monitors for intra intra ccardiaardiacc pressurepressure andand E ECCG G monitoring.monitoring. – –Emergent CPR Emergent CPR conditions and PCI materials.conditions and PCI materials.

Catheterisation methodsCatheterisation methods..

Arterial accessArterial access::• DireDirectct accessaccess.. Bra Brachchial arterial arteryy disse dissectction.ion.• PerPerccutanutaneouseous accessaccess.. Punction of rPunction of radial, adial,

brabrachchial, femoral arterial, femoral arteriesies..

Other ways of accessOther ways of access::1–1– Transeptal.Transeptal. For entrance to left atriumFor entrance to left atrium: :

For For mitral mitral vvalvuloplastalvuloplastyy in MS.in MS.Contraindications:Contraindications: Huge left atriumHuge left atrium, atriyal , atriyal

mimixxoma, toma, thhrombus ve rombus ve haemorhagichaemorhagic diatesisdiatesis..2– 2– DireDirectct LVLV p puunncturecture.. Conditions in which LV Conditions in which LV

cannot be entered throgh cannot be entered throgh mitral mitral andand aort aorticic valvesvalves: “Tilting-pro: “Tilting-prostesisstesis valvesvalves”. ”.

MajorMajor type of type of Heart CatheterisationHeart Catheterisation:: A- A- RIGHT HEART CATHETERISATIONRIGHT HEART CATHETERISATION::Vena Vena CCava, ava, Right-Right- atrium, atrium, Right-Right- ventri ventriccllee, , PPulmonulmonaarry-y-

arterarteryy, , Pulmonary- capillary wedge pressurePulmonary- capillary wedge pressure andand measurement of oxygene saturationmeasurement of oxygene saturation, , calculation of calculation of Cardiac output.Cardiac output.

ImportanceImportance: : 1-1- Measurement of right side pressures; Measurement of right side pressures; establish establish

prescence of Tricuspid or Pulmonary valves dysfunctıonprescence of Tricuspid or Pulmonary valves dysfunctıon and estimating sevirity.and estimating sevirity.

2- 2- Pulmonary hypertension can be evaluated and Pulmonary hypertension can be evaluated and pulmonary vascular resistance can be calculated.pulmonary vascular resistance can be calculated.

3-3- PulmonPulmonaarryy capillary wedge pressurecapillary wedge pressure; ; reflect the diastolic reflect the diastolic filling pressure of the left heart indirectly: Shows filling pressure of the left heart indirectly: Shows indirectly the left atrial and LV end- diastolic pressures.indirectly the left atrial and LV end- diastolic pressures. Is an important parameter in LV failure and MS.Is an important parameter in LV failure and MS.

B- B- LEFT HEART CATHETERISATIONLEFT HEART CATHETERISATION::• Mitral Mitral andand Aort Aort valvevalve f functionsunctions, s, syystemistemicc vascular resistancevascular resistance

andand LLV V function, and coronary artery anatomyfunction, and coronary artery anatomy..

ImportanceImportance::1-1- Most reliable diagnoses of AS and MS by pressure Most reliable diagnoses of AS and MS by pressure

calculations.calculations. (a)(a) MMSS:: Gradient between LGradient between LV diastoliV diastolic c – – Pulmonary capillary Pulmonary capillary

wedge pressure wedge pressure measurementsmeasurements..(b)(b) AASS:: Gradient is present between LV and systolic Aortic peak Gradient is present between LV and systolic Aortic peak

pressure when the catheter is pulled back from LV to the pressure when the catheter is pulled back from LV to the Aorta.Aorta.

2- 2- During catheterisation, prescence of AR and/or MR is shown:During catheterisation, prescence of AR and/or MR is shown: Contrast material is given by pump to the LV and Contrast material is given by pump to the LV and regurgitation of the contrast from LV to LA shows MR. When regurgitation of the contrast from LV to LA shows MR. When contrast is given from the Aorta at supravalvular level and contrast is given from the Aorta at supravalvular level and contrast regurgitates to the LV, AR is present.contrast regurgitates to the LV, AR is present.

3-3- Evaluation of LV functionEvaluation of LV function:: Beating LV is filled with contrast. Beating LV is filled with contrast. (a)(a) LV segmentar wall motion is evaluatedLV segmentar wall motion is evaluated.. (b)(b) LLV EF (% V EF (% frafractctionionaal l shorteningshortening) ) can be calculatedcan be calculated. .

4-4- Coronary angiographyCoronary angiography..

C- C- HEMODYNAMİC MESURMENTS:HEMODYNAMİC MESURMENTS:

1.1. Cardiac outputCardiac output..2.2. Pressure measurements of cardiac cavities and large Pressure measurements of cardiac cavities and large

arteries (aorta, pulmonary arteries)arteries (aorta, pulmonary arteries)..3.3. Evaluation of pressure waves.Evaluation of pressure waves.

4.4. Evaluation of valvular heart diseaseEvaluation of valvular heart disease..(a)(a) Assesment of Valvular stenosis and measurement Assesment of Valvular stenosis and measurement

of valve area. of valve area. (b)(b) Evaluation of valvular regurgitation.Evaluation of valvular regurgitation.5.5. Diagnosis of left and right shunts.Diagnosis of left and right shunts. 6.6. An Anggiograiographyphy..(a)(a) LeftLeft ventri ventricuculogralographyphy..(b)(b) RightRight ventri ventricuculogralographyphy..(c)(c) Aortogra Aortographyphy..

Normal Normal Heart and Coronary arteries AnatomyHeart and Coronary arteries Anatomy..

Left VLeft Ventrientricuculogralographyphy

Copyright ©2003 American Heart Association

Lange, R. A. et al. Circulation 2003;107:e111-e113

Typical catheters used for pressure measurements and angiography

Aort Aort andand Mitral Mitral stenosisstenosis: : Pressure Pressure gradients:gradients:

AS MS

D- D- CORONARY ANGIOGRAPHY:CORONARY ANGIOGRAPHY:

DIAGNOSTIC HEART CATHETERISATIONDIAGNOSTIC HEART CATHETERISATION Basic indicationsBasic indications::

1-1- Documentation or to rule out heart disease if there Documentation or to rule out heart disease if there is strong suspection by physical examination or non-is strong suspection by physical examination or non-invasive diagnostic tools.invasive diagnostic tools.

2-2- If there is discrepancy between clinical findigs and If there is discrepancy between clinical findigs and non-invasive diagnostic modalities, to lighten the non-invasive diagnostic modalities, to lighten the clinic situation.clinic situation.

3- 3- To evaluate other comorbid pathologic conditions in To evaluate other comorbid pathologic conditions in patient who has been given to open heart surgery patient who has been given to open heart surgery for any cause.for any cause.

Indications for Coronary AngiographyIndications for Coronary Angiography..

CLINICAL CONDITIONSCLINICAL CONDITIONS::

Essential İndicatıon:Essential İndicatıon: Known or suspected CAD. Known or suspected CAD. Asymptomatic patientAsymptomatic patient: : History of Previous MIHistory of Previous MI, PTCA, , PTCA, CABG, withCABG, with Ischemic findings on resting or exercise ECGIschemic findings on resting or exercise ECG..

1.1. Asymptomatic or stable anginaAsymptomatic or stable angina.. 2.2. Unstable coronary syndromeUnstable coronary syndrome.. 3.3. Post-revascularisation ischemiaPost-revascularisation ischemia.. 4.4. Primary treatment of AMİ with Primary treatment of AMİ with STSTEE oror LBBBLBBB in in

ECG.ECG. 5.5. Pre and post cardiac surgeryPre and post cardiac surgery.. 6.6. Patient with valvular disease.Patient with valvular disease.

7.7. Kon Konggenital enital heart diseaseheart disease.. 8.8. Congestive heart failureCongestive heart failure..

Unstable coronary syndromesUnstable coronary syndromes..

UUSAPSAP::

Stratified by biomarkers, hemodynamic and ECG findings.Stratified by biomarkers, hemodynamic and ECG findings.

• Refractory to initial treatment.Refractory to initial treatment.

• Recurrence of symptoms after becoming stable by initial Recurrence of symptoms after becoming stable by initial medical therapymedical therapy..

• High risk and complicated USAP. High risk and complicated USAP. (+ hemod(+ hemodyynaminamicc andand eleelecctritricalcal instabilit instabilityy): ): ””Urgent catheterisationUrgent catheterisation”” is is recommendedrecommended..

• Low risk patient at presentation; but high risk on non-Low risk patient at presentation; but high risk on non-invasive tests ( Ischemia at low- level exercise, EF invasive tests ( Ischemia at low- level exercise, EF <0.40). <0.40).

• Suspected Suspected Prinzmetal VarPrinzmetal Variiant angina.ant angina.

Treatment of STE- AMITreatment of STE- AMI

1.1. PriPrimarymary PTCA (+) PTCA (+) coronary angiographycoronary angiography::a-a- Alternative to Alternative to TThhrombolrombolyytiticc therapytherapy: : Ongoing ischemic Ongoing ischemic

symptoms,symptoms, <12 <12 oror >12 >12 hrs hrs ((experiencedexperienced staffstaff andand appropriateappropriate laboratlaboratoorryy).).

b-b- Cardiogenic Shock:Cardiogenic Shock: In the first 36 hrs of MI, In the first 36 hrs of MI, (<75 (<75 yrsyrs andand in in 18 18 hrs of shockhrs of shock).).

C- C- Thrombolytıc contrindicatıons.Thrombolytıc contrindicatıons.

d-d- Failed Thrombolysis ( Failed Thrombolysis (Rescue PTCARescue PTCA).).

2. 2. Patients not going to primary PTCA:Patients not going to primary PTCA: Reasonable for Reasonable for patients with cardiogenic shock or persistant unstable patients with cardiogenic shock or persistant unstable hemodynamy.hemodynamy.

Suspected mechanical complications intended for surgery.Suspected mechanical complications intended for surgery.

3. 3. Early coronary angiographyEarly coronary angiography::a- a- Spontaneously or stimulated recurrent or ongoing ischemic Spontaneously or stimulated recurrent or ongoing ischemic

episodes.episodes. ( (dynamic ECG changesdynamic ECG changes:: ±±).).

b-b- Cardiogenic shock, severe pulmonary congestion, or ongoing Cardiogenic shock, severe pulmonary congestion, or ongoing hypotension.hypotension.

Relative Contraindications.Relative Contraindications.

1-1- Decompensated HFDecompensated HF ( (Pulmonary EdemaPulmonary Edema).).2- 2- Uncontrolled ventricular irritabilityUncontrolled ventricular irritability ( (arrythmia with arrythmia with

hemodynamic compromisehemodynamic compromise).).3- 3- Uncontrolled systemic hypertensionUncontrolled systemic hypertension..4-4- Acute and severe renal failure Acute and severe renal failure..5- 5- Inability of vascular accessInability of vascular access..6-6- Electrolyte imbalanceElectrolyte imbalance: H: Hyypopokalemiakalemia, H, Hyyperperkalemiakalemia..7- Di7- Diggital intoital intoxxiiccaationtion..8-8- A Acctivtivee infe infectionction andand septic conditionsseptic conditions..9- 9- Uncontrolled Haemorrhagic diastesisUncontrolled Haemorrhagic diastesis..10- 10- Severe anemiaSevere anemia..11- A11- Acctivtivee haemmorhagehaemmorhage..12- 12- Contrast allergyContrast allergy..13- 13- Loss of consciousnessLoss of consciousness..

* **!!!-* **!!!- ABSOLUTE CONTRAINDICATIONABSOLUTE CONTRAINDICATION:: Disclaim of Disclaim of conscious patient.conscious patient.

COMPLICATIONS:COMPLICATIONS:Complication prevalance was reduced as the number of Complication prevalance was reduced as the number of

procedures was increased in any centerprocedures was increased in any center (!).(!).

MAJOR MAJOR ComplicationsComplications (%0.2- 0.3): (%0.2- 0.3): DeathDeath, AM, AMII, SV, SVAA..

****** DEATHDEATH (%0.1- 0.2 ). (%0.1- 0.2 ).

CauseCause:: PerforationPerforation, ar, arrythmiarythmia, AM, AMII, , oror ccontrast anaontrast anaphyphylalaxxis.is.

Patients with Hıgh- Rısk of DeathPatients with Hıgh- Rısk of Death (risk %2.8): (risk %2.8):

1-1- PatientsPatients >70, >70, <1 y<1 yearsears. .

2-2- NYHA-4 NYHA-4 HFHF oror angina. angina.

3-3- SevereSevere LLV dV dyysfsfuunnctionction (EF<%25). (EF<%25).

4-4- Severe and extensive CADSevere and extensive CAD (LMCA, 3- (LMCA, 3- vesselvessel diseasedisease). ).

5-5- Severe valvular diseaseSevere valvular disease ( (withwith LLV dV dyysfsfuunnctionction). ).

6-6- SevereSevere ccomorbid omorbid conditionsconditions ( (renalrenal,, hepatic hepatic,, lung lung diseasedisease). ).

7-7- KnownKnown ccontrast allerontrast allergygy..

Contrast nephropathyContrast nephropathy: : Is generally secondary to high doses of contrast material, Is generally secondary to high doses of contrast material,

and especially develops in diabetic patients.and especially develops in diabetic patients.

PreventionPrevention::

a-a- Dose of the contrast material must be calculated Dose of the contrast material must be calculated according to the patients body surface area, weight and according to the patients body surface area, weight and serum creatinin levels. serum creatinin levels.

b-b- Non-ionic contrast material is the prefereNon-ionic contrast material is the prefere..

c- c- Before vatheterization, oral homosistein can be given Before vatheterization, oral homosistein can be given and bicarbonate infusion can be made. and bicarbonate infusion can be made.

d-d- In patients using diuretics, the diuretic dose befor In patients using diuretics, the diuretic dose befor catheterization must be passed, and especially in catheterization must be passed, and especially in diabetics, iv hydration must be increased. IV hydration diabetics, iv hydration must be increased. IV hydration must be continued during the procedure if needed.must be continued during the procedure if needed.

e-e- During the 6-12 hour period after catheterization, oral During the 6-12 hour period after catheterization, oral and iv hydration must be sufficient (1.5 – 2 Lt).and iv hydration must be sufficient (1.5 – 2 Lt).

PERCUTANEOUS CORONARY PERCUTANEOUS CORONARY INTERVENTIONINTERVENTION

DefinitionDefinition:: Is the treatment intended percutaneous Is the treatment intended percutaneous coronary procedure.coronary procedure.

• Was known as “PTCA” in the past. Was known as “PTCA” in the past.

For optimal procedureFor optimal procedure:: Standart Standart catheterization catheterization laboratlaboratory, dilatation material and experienced staff ory, dilatation material and experienced staff able to use these material must be present. able to use these material must be present.

Ideal patientIdeal patient:: (a)(a) One vessel diseaseOne vessel disease..(b)(b) Patients, performed CABG at past; has fragile and old Patients, performed CABG at past; has fragile and old

lesion; lesion; (“(“disdisccretretee:: length length <10 mm. <10 mm. Diameter of the Diameter of the vesselvessel:>2.5 mm):>2.5 mm); ; 3 3 vessel disease withvessel disease with high success high success rate rate ..

(c)(c) In the case of ACS and especially STEMI, primary In the case of ACS and especially STEMI, primary treatment choice is percutaneous coronary treatment choice is percutaneous coronary intervention.intervention.

• Power of Power of PPCICI:: To be successfull in To be successfull in >%90>%90 of cases of cases..

Limitations of PCI:Limitations of PCI:

1-1- Success rate is low in chronic total occlusions.Success rate is low in chronic total occlusions. 2-2- Early and long term efficasy is low in Early and long term efficasy is low in saphenoussaphenous vein vein

greft legreft lesions.sions.HIGHHIGH- R- Riskisk Stenoti Stenoticc Le Lesisiononss::a-a- Di Diffuseffuse (>20 mm). (>20 mm). Vessel DiameterVessel Diameter: <1.5- 2.0 mm.: <1.5- 2.0 mm.b- b- DenseDense tort tortuous-uous- pro proxximal segment.imal segment.c- c- SeverelySeverely angulatedangulated segm segmeent (≥90 dent (≥90 degegee).e).d-d- Total o Total occcclulusision (>3 on (>3 monthsmonths). De). Degeneratedgenerated ve veiin greftn greft

(fra(fragygyl lel lesionsion).).e- e- Ostial leOstial lesisiononss, , side branch originating from the side branch originating from the lelesision.on.

Advers effects of the interventionAdvers effects of the intervention::a- a- Fatal Fatal eventevent (%1). (%1).b-b- A Accututee andand latelate is ischchemiemicc complicationscomplications (%2). (%2).c-c- Signifficant restenosis in the first months.Signifficant restenosis in the first months. (%10). (%10).

Complications of PCIComplications of PCI::

1. 1. MortalityMortality. .

(a) (a) In stable patientsIn stable patients: <%2. : <%2.

(b) AM(b) AMII + + CS CS : >%50).: >%50).

2. M2. Myyooccardardialial IInfarnfarccttionion. .

Elevation of cardiac markersElevation of cardiac markers: %5- 10.: %5- 10.

3. 3. No- (Re)Flow:No- (Re)Flow: Proksimal Proksimal vessel is openvessel is open, , but myocardial but myocardial tissue is not perfusedtissue is not perfused..

Vasoactive materials emanating by the disintegration or Vasoactive materials emanating by the disintegration or breaking up of the thrombus of the pbreaking up of the thrombus of the proroxximal leimal lesisionon and microembolisationand microembolisation..

DiagnosisDiagnosis: : Elevation of cardiac markersElevation of cardiac markers, ST- T , ST- T wave wave changes on ECGchanges on ECG andand regional wall motion regional wall motion abnormalitiesabnormalities..

4. 4. Coronary perforation and rupture.Coronary perforation and rupture.

STENTSTENTSS..

Are the supplementary components of balloons.Are the supplementary components of balloons. Rutine stenting has become the rutine procedure of PCI.Rutine stenting has become the rutine procedure of PCI.

(“(“DirekDirektt Stent Stentinging”).”).

TTypesypes:: • Drug elutingDrug eluting AAcctitive ve - Stent- Stentss (“Drug Eluting Stent (“Drug Eluting Stent””)).. • Metal,Metal, PassiPassive- ve- Stent Stents (Bare- Stent”)s (Bare- Stent”)..

Difficulties of PCI:Difficulties of PCI:a-a- Passing chronic total occlusion.Passing chronic total occlusion.b-b- Optimization of anti-thrombotic and anti-thrombin Optimization of anti-thrombotic and anti-thrombin

therapies for acute total occlusions.therapies for acute total occlusions.c-c- Retsenosis is a problem, although overwhelm and Retsenosis is a problem, although overwhelm and

decreasing with Active- stents.decreasing with Active- stents. Although acute, subacute Although acute, subacute restenosis decreases more compared withpassive stents, restenosis decreases more compared withpassive stents, but late restenosis in 2 years is more frequent in DES. but late restenosis in 2 years is more frequent in DES.

INDICATIONS OF PCIINDICATIONS OF PCI::

CLINICAL INDICATIONSCLINICAL INDICATIONS::

1-1- Acute Cornary SyndromesAcute Cornary Syndromes: STEM: STEMII,, NSTEMNSTEMII, , USAPUSAP).).

2- 2- StabStablele AP: Po AP: Possitiitiveve exercise testingexercise testing, , LLV disfV disfuunnctction, ion, elevtrical instabilityelevtrical instability..

3-3- Angina eAngina equivalentsquivalents: : ArrythmiaArrythmia, , lliightheadnessghtheadness, , ddyyspnespneaa..

4-4- MSMS - CT’de; - CT’de; Sign of proximal stenosis.Sign of proximal stenosis.

5-5- Objective signs of reversible ischemia.Objective signs of reversible ischemia.

ANGIOGRAPHIC INDICATIONSANGIOGRAPHIC INDICATIONS::

1-1- 1-4 Lesions are apopriate for 1-4 Lesions are apopriate for PPCI.CI.

2- 2- There is no life threatening effects of occluding these There is no life threatening effects of occluding these lesions for ≥1 minute.lesions for ≥1 minute.

3-3- Prescence of functional myocardium or collateralls.Prescence of functional myocardium or collateralls.

CONTRAINDICATIONS FOR PCICONTRAINDICATIONS FOR PCI::

CLINICAL CONTRAINDICATIONSCLINICAL CONTRAINDICATIONS::1-1- Terminal heart disease or other disease (except uncontrolled Terminal heart disease or other disease (except uncontrolled

AP).AP).2- 2- PostPost--MMII CSCS ( (with multiorgan failurewith multiorgan failure).).

ANGIOGRAPHIC CONTRAINDICATIONSANGIOGRAPHIC CONTRAINDICATIONS::1- 1- LMCALMCA disease disease. . 2- 2- LMCA LMCA equivalentequivalent: Pro: Proxximal LAD + CX imal LAD + CX diseasedisease..3-3- Last vesselLast vessel: : OtherOther 2 2 coronary artery occludedcoronary artery occluded..4- 4- Three vessel diseaseThree vessel disease ( (except inop patientexcept inop patient).).

5- 5- Characteristics of hard lesionsCharacteristics of hard lesions::(a)-(a)- Chronic total occlusionChronic total occlusion..(b)-(b)- No collateral to the distal artery.No collateral to the distal artery. (c)-(c)- Diffuse old lesionDiffuse old lesion (>20 mm). (>20 mm).(d)-(d)- No cut off.No cut off...(e)(e)- - No critical CAD in the prescence of thrombotic lesion.No critical CAD in the prescence of thrombotic lesion. • (f)-(f)- Diffu Diffusese atherosclerotic or small diameter vessel atherosclerotic or small diameter vessel (<2 mm). (<2 mm).

SaSaphenousphenous ve veiin greft. n greft.

Materials for PCIMaterials for PCI::

Mechanism of PTCA and StentingMechanism of PTCA and Stenting..

• Dissection of intima and media in the nneighbor sections Dissection of intima and media in the nneighbor sections of the vessel near the plaque.of the vessel near the plaque. Circumferential dilatation Circumferential dilatation of the vessel is the key mechanism for luminal increase of the vessel is the key mechanism for luminal increase (increasing diameter). (increasing diameter).

• STENT:STENT: Is the key material for preventing “elastic recoil Is the key material for preventing “elastic recoil of the widening vessel.of the widening vessel. Keeps the plaque particles and Keeps the plaque particles and intima away from the luminal surface.intima away from the luminal surface.

BaloBalooon n andand + Stent. + Stent.

ADDITIONAL THERAPİESADDITIONAL THERAPİES::1.1. Oral Oral-- Anti Antiplateletplatelet : ASA, : ASA,

CClopidogrel.lopidogrel.2.2. İV İV-- AAntintiplateletplatelet : : GP-GP-2b/3a 2b/3a

İnh.İnh.3.3. Antit Antithhrombin: Heparinrombin: Heparin, ,

Bivaluridin, FondaparinuxBivaluridin, Fondaparinux..

Efficacy of PCIEfficacy of PCI::a- a- Success rate of the Success rate of the

intervention.intervention. b-b-Symptomatic reliefSymptomatic relief after after

intervention:intervention: %90. %90.c-c- ComplicationsComplications:: ≤ %2. ≤ %2.

Schematized STENTINGSchematized STENTING..• Beginning of the Beginning of the

procedureprocedure: : Angaging the Angaging the guiding catheter guiding catheter successfully to the successfully to the coronary ostiyum and coronary ostiyum and passing the guide wire passing the guide wire hrough the lesion.hrough the lesion.

• A-A- Passing the stented Passing the stented ballon from the stenotic ballon from the stenotic lesion.lesion. Before this,Before this, standart predilatation of standart predilatation of the lesion mey be needed.the lesion mey be needed.

• B-B- Inflating the ballon and Inflating the ballon and widening of the stent. widening of the stent.

• C-- D-C-- D- Deflating the Deflating the balloon and pulling back balloon and pulling back from the widened stent. from the widened stent.

Coronary AngiographyCoronary Angiography: : SuccessfullSuccessfull STENT STENTING.ING.

Percutaneous Mitral Baloon Valvotomy(PMV)

Percutaneous ASD Closure

İndicatıons: • Symptoms of dyspne,fatigue or RHF.• Reccurrent pulmonary infectıon.• Paradoxical embolism.• Atrial arrhytmia even ın the presence of a small defect.• Moderate Pulmonary hypertensıon without pulmonary vascular disease.• Asymptomatic large ASD (Qp/Qs>1.5:1.0),RH volum overload and no pulmonary hypertensıon.

İnd: Echo score <8. • MVA<1.0 cm2.• No subvalvular fibrosis,• mobile valve and noncalcified.

ICD: Implantable Cardioverter Defibrillator(Chest Radiograph)

İndication:• Reduced EF who had history of cardiac arrest,VT,VF.• Ischemic CMP; at least 40 days post-MI with EF <%30, NYHA II or III on chronic OMT.

CRT: Cardiac Resynchronısatıon Therapy

İndicatıon:

• LVEF<%35.• Sinus rhym. • NYHA class –III-IV, despite optimal therapy.• Have cardiac dyssynchrony, QRS duratıon >120 ms.